COMMENTARY
Homosexuality, Psychopathology, and Suicidality
I
N THIS issue of the ARCHIVES,
Herrell et al1 report a study
in which they assessed sui-
cidalideation,historyofever
attempting suicide, and psy-
chopathology in male twins who had
sex with other men after age 18 years
and in their heterosexual co-twins.
This study is the first in which psy-
chopathology and suicidality are
compared between twins of diver-
gent sexual orientation recruited from
a population-based twin registry. Her-
rell and coauthors conclude that
homosexual men have an increased
lifetime risk of suicidal behaviors and
that this is unlikely to be owing to
psychiatric comorbidity. The first
part of this conclusion seems more
strongly supported by the study than
the second. In particular, the infer-
ence about the lack of relationship be-
tween depression and suicidality
must be taken with caution. Statisti-
cal operations correlating depres-
sion and suicidality were carried out
using a variable representing the
number of symptom groups re-
ported for the worst period of a sub-
ject’s depression.
See also pages
867 and 876
Not inquired about were the du-
ration of each depressive episode, the
number of episodes, and the age at on-
set of depression, all of which might
have influenced suicidality. Neither
age at suicide attempt nor number of
attempts were included in the inves-
tigation. The subjects were appar-
ently not asked about the relation-
ship between the onset of their
homosexual desires and activity, the
onset of depression, and the history
of attempted suicide. Usually the fan-
tasy dimension of sexual orienta-
tion—homoerotic imagery associ-
ated with sexual excitement and
masturbation—precedes interper-
sonal sexual activity by many years.2
Thus, an adolescent or preadoles-
cent child may feel alienated and/or
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depressed because of homosexual de-
sires that are in conflict with his con-
science and the values of others long
before the adolescent or preadoles-
cent child becomes sexually active
with others.
DEPRESSION AND
SUICIDALITY
Although social factors (eg, homo-
phobia) may influence suicidality, so
may the state of mind of the person
who is suicidal. This requires particu-
lar emphasis since the contempo-
rary psychiatric climate of belief tends
to underemphasize the relevance of
the biopsychological-social develop-
mental model for understanding psy-
chological functioning and psycho-
pathology.3,4 Common sense and
clinical judgment suggest a meaning-
ful link between depression and sui-
cidality that might have been uncov-
ered had the assessment instrument
been different. This having been said,
the increased risk of suicidality among
men who have had male sexual part-
ners reported in this investigation is
significant both from statistical and
clinical perspectives.
Herrell et al1 also did not inves-
tigate chronological relationships be-
tween sexual orientation and suicid-
ality; however, they note that other
research suggests that adolescence is
a time of particular risk. In this is-
sue, Fergusson et al5 studied this more
directly by using data collected an-
nually from subjects until age 16 years
and subsequently at ages 18 and 21
years. They conclude that gay, les-
bian, and bisexual (GLB) youth are
indeed at an increased risk of sui-
cidal behavior and psychiatric disor-
ders. The investigators placed those
self-labeling as GLB into a common
pool for data analysis perhaps be-
cause of the relatively small number
of GLB subjects in the study. Of 1007
people assessed at age 21 years, only
20 self-identified as GLB. Although
understandable, placing GLB pro-
bands in the same group is problem-
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887
atic. The social circumstances of
people self-labeling as homosexual are
often different from those self-
labeling as bisexual since in most
Western industrialized countries there
is no bisexual social niche. Gay and
lesbian subcultures occur among di-
verse societies; however, their vital-
ity and degree of acceptance by the
conventional heterosexual majority
varies across geographical regions. It
would have been helpful to know
more about the gay and lesbian sub-
culture in New Zealand, the site of this
study, and the degree to which it is
accepted by mainstream society.
Controlling statistically for the
history of childhood difficulties, Fer-
gusson et al5 conclude that a his-
tory of early parental change and/or
parental criminality does not influ-
ence the association between sexual
orientation and psychopathology.
Many relevant developmental is-
sues are not addressed with this type
of statistical manipulation, how-
ever, including age at which criti-
cal stressors occurred, duration of
parental neglect and/or abuse, anti-
homosexual attitudes within the
family, degree of supportiveness of
parental figures, onset of sexual ori-
entation, history of atypical sex-
role behavior and parental reaction
to it, and whether subjects dis-
closed homosexual desires to par-
ents before age 14 years. For ex-
ample, consider 2 families with the
same number of parental change
events experienced by children be-
fore age 14 years. In one, the events
occurred when the child was be-
tween ages 0 and 5 years and in the
other, between ages 8 and 13 years.
From a clinical perspective, the fami-
lies are not entirely comparable.
Moreover, among families of GLB
youth, a parent’s partner who was
not antihomosexual may have left
the family to be replaced by a pa-
rental partner who was. Although
parental substance abuse and crimi-
nality were assessed by Fergusson et
al, additional information would
 have been helpful, specifically re-
garding parental depression and sui-
cidality. Given the small number of
GLB subjects, a family pedigree of
each would have been informative.
NEED FOR ADDITIONAL
RESEARCH ON HOMOPHOBIA,
DEPRESSION, AND
SUICIDALITY
The 2 studies of homosexuality re-
ported in this issue of the ARCHIVES
point to a need for research in a num-
ber of areas. Although acceptance of
gay men and lesbians has increased
in recent decades, antihomosexual
prejudice still remains a consider-
able problem in many societies and
subcultures within societies. Homo-
phobic acts vary along a spectrum of
severity from devaluation and ver-
bal abuse to physical threat, assault,
and even homicide.6-8 Most gay and
lesbian people are raised in hetero-
sexually oriented, traditional fami-
lies, and many are exposed to par-
ents, siblings, and others who are
overtly homophobic. During preado-
lescence and young adulthood, en-
counters with homophobic peers are
probably the rule rather than the ex-
ception. Direct study of the effects of
homophobia on the psychopathol-
ogy and suicidality of gay youth is
therefore needed.
In addition to the immediate ef-
fectsofantihomosexualprejudice,past
traumas resulting from homophobia
may also influence psychological ad-
justment later in life. Negative inter-
nalizations may adversely influence
self-esteem and the sense of security
of gay and lesbian people.9-13 It is
important to assess chronological re-
lationships during the development
between antihomosexual abuse by
family members and peers and the
ways in which the homosexual per-
son attributes depression and dimin-
ished self-esteem to such abuse.
Whereas chronological relation-
ships between self-labeling as lesbian
and the onset of sexual attraction vary
among women, men usually realize
that they are sexually attracted to boys
andmenwellbeforepuberty.14 Among
both sexes, however, there is often a
delay of months to years between the
time that the person realizes his or her
homosexuality and the time that oth-
ers are told about it.15 The reason for
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hiding one’s sexual orientation (the
vernaculartermis“beinginthecloset”)
isusuallyconcernabouthomophobia.
Shame and guilt, sometimes about ho-
mosexual desires but often about di-
minished self-authenticity resulting
from masquerading as heterosexual,
are often intense during this develop-
mental phase. Relationships between
psychological adjustment, suicidality,
social stress, and hiding vs revealing
one’s sexual orientation also require
systematic research.
The area of atypical childhood
sex-role behavior, not addressed in ei-
ther investigation, is important in the
development of many gay and lesbian
people.Bothgaymenandlesbianshave
histories of more childhood atypical
sex-role behaviors than heterosexual
people.16 Perhapsbecausemenareless
tolerant of such behavior than wom-
en, childhood atypical sex-role behav-
ior has been reported to be associated
with depression, anxiety, and suicid-
ality in men17-19 but not women.20,21
Further studies of chronological rela-
tionships between sex-role behavior
and the attitudes of parents and peers
toward it, the onset of sexual orienta-
tion,andpsychopathologymightshed
lightonopenquestionsconcerninggay
and lesbian development.
Neither the American nor the
New Zealand study assessed human
immunodeficiency virus status in sub-
jects themselves or their partners. The
prevalence of human immunodefi-
ciency virus seropositivity varies
across societies, and it may be an im-
portant confounding variable in stud-
ies of the behavior of gay men.
The major findings reported by
Herrell et al1 and by Fergusson et al5
are compatible with other recently re-
ported data.22 There is clearly a need
for additional investigation of the as-
sociations between sexual orienta-
tion, suicidality, and psychopathol-
ogy. Collaborative research between
developmentally oriented clini-
cians, descriptive psychiatrists, and
epidemiologists might help distin-
guish between causes and conse-
quences of these associations.
Richard C. Friedman, MD
Weill Medical College
of Cornell University
Payne Whitney Clinic
New York Presbyterian Hospital
New York, NY 10021
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888
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